You are the Key to HPV Cancer Prevention Hello, my name is <name> and I am the <title> at <organization>. I will be presenting You are the Key to HPV Cancer Prevention.

Instructions for Presenters Be sure to customize the title slide This slide deck should be adjusted to fit your allotted time and personal style of presenting Rather than deleting slides to shorten the presentation, simply hide the slides you do not want to show Replace the content on this slide with your disclosures statement If pharmacy continuing education credit is not being provided, you may remove the last objective on the next slide <please insert your disclosure statement here>

Objectives Describe why HPV vaccination is important for cancer prevention. Identify the appropriate HPV vaccination schedule based on patient age. Describe effective HPV vaccine recommendations for patients age 11 or 12 years, as well as for age 13 years and older. Develop self-efficacy in delivering effective HPV vaccination recommendations Identify reassuring, confident, and concise responses to parental questions about HPV vaccination. Implement disease detection and prevention health care services (e.g., smoking cessation, weight reduction, diabetes screening, blood pressure screening, immunization services) to prevent health problems and maintain health. (REQUIRED FOR PHARMACY CREDIT) When this presentation is complete, you should be able to: one, describe why HPV vaccination is important for cancer prevention; two, identify the appropriate HPV vaccination schedule based on patient age; three, describe effective HPV vaccine recommendations for patients age 11 or 12 years, as well as for age 13 years and older; four, develop self-efficacy in delivering effective HPV vaccination recommendations; five, identify reassuring, confident, and concise responses to parental questions about HPV vaccination; and six, implement disease detection and prevention health care services (e.g., smoking cessation, weight reduction, diabetes screening, blood pressure screening, immunization services) to prevent health problems and maintain health.

HPV Infection & Disease Understanding the Burden HPV Infection & Disease The first section will focus on HPV infection and disease prevalence.

HPV Types Differ in Their Disease Associations Mucosal sites of infection Cutaneous ~ 80 Types “Common” Hand and Foot Warts ~40 Types Genital Warts Laryngeal Papillomas Low-Grade Cervical Disease Low risk (non-oncogenic) HPV 6, 11 most common High risk (oncogenic) HPV 16, 18 most common Cervical Cancer Anogenital Cancers Oropharyngeal Cancer Cancer Precursors Human papillomaviruses (HPV) are a very common family of viruses that infect epithelial tissue. HPV types differ in their tendency to infect cutaneous and mucosal or genital epithelium. More than 150 HPV types have been identified, including approximately 40 that infect the genital area. Genital HPV types are categorized according to their epidemiologic association with cervical cancer. High-risk types (e.g., types 16 and 18) can cause low-grade cervical cell abnormalities, high-grade cervical cell abnormalities that are precursors to cancer, and cancers. In addition to cervical cancer, HPV infection also is the cause of some cancers of the vulva, vagina, penis, and anus, as well as cancer of the oropharynx. Low-risk types like 6 and 11 can cause benign or low-grade cervical cell changes, genital warts, and recurrent respiratory papillomatosis.

HPV Infection Most females and males will be infected with at least one type of mucosal HPV at some point in their lives Estimated 79 million Americans currently infected 14 million new infections/year in the US HPV infection is most common in people in their teens and early 20s Most people will never know that they have been infected Most HPV infections happen during the teen and college-aged years because HPV infection usually occurs soon after sexual debut. Most people never know that they have been infected. Women may find out they are infected because of an abnormal pap test with a positive HPV test or a diagnosis of genital warts. Men may find out because of a genital warts diagnosis as well. Satterwhite et al. Sex Transm Dis. 2013

Cancers Caused by HPV per Year, U.S., 2010–2014  Cancer site Percentage probably caused by any HPV type Number probably caused by any HPV type Female Male Both Sexes Cervix 91% 10,600 Vagina 75% 600 Vulva 69% 2,600 Penis 63% 800 Anus* 3,800 1,900 5,700 Oropharynx 70% 2,100 10,100 12,200 TOTAL 19,700 12,800 32,500 This slide shows the numbers that were displayed in the figure in the previous slide and focuses in on the number of cancers attributable to HPV per year in the United States from 2010 to 2014. An HPV-attributable cancer is a cancer probably caused by HPV. The column with “percentage probably caused by any HPV type” comes from the CDC genotyping study. HPV causes nearly all cervical cancers and many cancers of the vagina, vulva, penis, anus (including rectal squamous cell carcinoma), and oropharynx. CDC estimated that during 2010 to 2014, HPV caused about 32,500 cancers in the United States each year, with 19,700 cancers in women and 12,800 cancers in men. Most HPV-associated cancers in women were cervical cancers while, in men, most were oropharyngeal cancers. *Includes anal and rectal squamous cell carcinomas Sources: https://www.cdc.gov/cancer/hpv/statistics and Saraiya M et al. J Natl Cancer Inst. 2015;107:djv086

Estimated Number of Cancer Cases Attributable to HPV by Sex, Cancer Type, and HPV Type, United States, 2010–2014 This slide shows the number of HPV-Associated Cancer cases that were diagnosed and reported each year in United States from 2010 to 2014 (the most recent 5-year period with available data) by sex, cancer type, and HPV-type. Cancer registries do not routinely collect data on whether HPV is in the cancer tissue. So, to estimate the number of HPV-associated cancers, researchers look at cancer in parts of the body and cancer cell types that are likely to be caused by HPV. These include all carcinomas of the cervix and squamous cell carcinomas of the vagina, vulva, penis, anus (including rectal squamous cell carcinomas), and oropharynx, which is the back of the throat, including the base of the tongue and the tonsils. Additionally, in this analysis, all cancers were microscopically confirmed. A CDC study published in 2016 used population-based data to genotype HPV types from cancer tissue. These data are used to estimate the percentage of these cancers that are probably caused by HPV, what we call HPV-attributable cancers. This graph shows the total number of HPV-associated cancers and uses the attributable fractions from the genotyping study to estimate the number probably caused by HPV types. HPV types were grouped as 16/18 (the dark blue bar), other high risk types 31/33/45/52/58 (the medium blue bar), and other HPV types (light blue bar). The white bar means that HPV DNA was not detected. https://www.cdc.gov/cancer/hpv/statistics

HPV-Associated Cancer Rates by Sex, Race, and Ethnicity, United States, 2010–2014 This graph shows the incidence of all HPV-associated cancers (all carcinomas of the cervix and squamous cell carcinomas of the vagina, vulva, penis, anus [including rectal squamous cell carcinomas], and oropharynx) by sex, race and ethnicity. “Incidence rate” means how many people out of a given number get the disease each year. Incidence rates of HPV-associated cancers varied by sex and race or ethnic group. The rate for women is shown in the solid bar and the rate for men is shown in the hatched bar. In each race/ethnic group, women had higher rates than men. Among women, blacks and whites had higher rates and Asian/Pacific Islanders had lower rates compared with other racial groups. Among men, whites had the highest rates and Asian/Pacific Islanders had the lowest rates compared with other racial groups and non-Hispanics had higher rates than Hispanics. https://www.cdc.gov/cancer/hpv/statistics

HPV-Associated Anal* Cancer Rates by Sex, Race, and Ethnicity, United States, 2010–2014 It is estimated that about 4,100 new cases of HPV-associated anal cancers (including rectal squamous cell carcinoma) were diagnosed in women and about 2,100 in men each year during 2010-2014 in the United States. Rates of HPV-associated anal cancer were higher in women than in men overall and in each racial and ethnic group, except for black women who had similar rates as black men. White women had higher rates of HPV-associated anal cancer than women of other races. Black men had higher rates of HPV-associated anal cancer than men of other races. *Includes anal and rectal squamous cell carcinomas. https://www.cdc.gov/cancer/hpv/statistics

HPV-Associated Oropharyngeal Cancer Rates by Sex, Race, and Ethnicity, United States, 2010–2014 Some cancers of the oropharynx, which includes the back of the throat, including the base of the tongue and the tonsils, have been linked with HPV. It is estimated that about 3,300 new cases of HPV-associated oropharyngeal cancers were diagnosed in women and 14,000 were diagnosed in men each year during 2010-2014 in the United States. These numbers are based on cancers in specific areas of the oropharynx and do not include cancers in all areas of the head and neck or oral cavity. Men had higher rates of HPV-associated oropharyngeal cancer than women. White men and women had higher rates of HPV-associated oropharyngeal cancers compared with other racial groups and non-Hispanic men and women had higher rates of HPV-associated oropharyngeal cancers compared with Hispanic men and women. https://www.cdc.gov/cancer/hpv/statistics

HPV-Associated Penile Cancer Rates by Race, and Ethnicity, United States, 2010–2014 Penile cancers are rare. It is estimated that about 1,200 new cases of HPV-associated penile cancers were diagnosed in the United States each year during 2010-2014. Black and white men had higher rates of HPV-associated penile cancer than other racial groups and Hispanic men had higher rates of HPV-associated penile cancer than non-Hispanic men. https://www.cdc.gov/cancer/hpv/statistics

HPV-Associated Vaginal Cancer Rates by Race, and Ethnicity, United States, 2010–2014 Vaginal cancers are also rare. It is estimated that about 800 new cases of HPV-associated vaginal cancer were diagnosed in the United States each year during 2010-2014. Black women had higher rates of HPV-associated vaginal cancer than women of other races, similar to cervical cancer. https://www.cdc.gov/cancer/hpv/statistics

HPV-Associated Vulvar Cancer Rates by Race, and Ethnicity, United States, 2010–2014 Vulvar cancers are also rare. It is estimated that about 3,800 new cases of HPV-associated vulvar cancer were diagnosed in the United States each year during 2010-2014. White women had higher rates of HPV-associated vulvar cancer than women of other races. https://www.cdc.gov/cancer/hpv/statistics

HPV-Associated Cervical Cancer Rates by Race, and Ethnicity, United States, 2010–2014 This graph shows the incidence of HPV-associated cervical cancers by race and ethnicity. “Incidence rate” means how many people out of a given number get the disease each year. Black and Hispanic women had higher rates of HPV-associated cervical cancer than women of other races or ethnicities, possibly because of decreased access to Pap testing or follow-up treatment. It is estimated that about 12,000 new cases of HPV-associated cervical cancer were diagnosed in the United States each year during 2010 -2014. https://www.cdc.gov/cancer/hpv/statistics

Cervical Cancer Cervical cancer is the most common HPV-associated cancer among women 528,000 new cases and 266,000 deaths worldwide in 2012 13,000 new cases and 4,000 deaths in the U.S. in 2014 Half of cervical cancers occur in women <50 years A quarter of cervical cancers occur in women 25-39 years Cervical cancer was once the leading cause of cancer death for women in the United States. Now it is the most preventable of all of the female cancers. The Pap test has helped decrease the number of women in the U.S. diagnosed with cervical cancer by about 75% in the past 50 years. However even with an excellent cervical cancer screening program in the U.S., there are still about 12,000 to 13,000 new cases of cervical cancer and 4,000 deaths each year in this country. No women should die of cervical cancer. Worldwide, cervical cancer is the 4th most common cancer among women, and in some countries, it is the most common. Half of cervical cancer cases in the United States occur in women younger than 50 years, with 1 in 4 of cervical cancer cases among women age 25-39 years, during prime reproductive years. A cervical cancer diagnosis and treatment may be devastating to women and their families for a variety of reasons, including negative effects on their health, welfare, finances, and ability to work. Cervical cancer is treated at minimum with the removal of the cervix but may also include radical hysterectomy, radiation, and/or chemotherapy. https://nccd.cdc.gov/uscs/ and http://gco.iarc.fr/today/home

Cervical Pre-Cancer in U.S. Females 1.4 million new cases of low-grade cervical dysplasia 330,000 new cases of high-grade cervical dysplasia When some people talk about HPV disease the focus is usually on the 12,000 cases of cervical cancer and the 4,000 deaths. But as you can see in this slide, every year 1.4 million women will be diagnosed with low grade cervical dysplasia. Each of these women was faced with the emotionally trying news of an abnormal pap test, a colposcopy with biopsy that are done without local or general anesthesia, waiting to hear whether or not they have cancer. More than 300,000 women in the United States are diagnosed with high grade cervical dysplasia, or cervical precancer. To receive this diagnosis each of these women have undergone a colposcopy with biopsies. After receiving the diagnosis many will go on to have a LEEP procedure or a cold-knife cone biopsy of the cervix, which is shown in the image. Preventing cancer is better than treating it. Preventing the infections that can lead to cancer is even better. Koshiol Sex Transm Dis. 2004. Schiffman Arch Pathol Lab Med. 2003.

HPV Vaccine Evidence-Based HPV Disease Prevention This next section will focus on HPV vaccine recommendations. HPV Vaccine

HPV Prophylactic Vaccines Recombinant L1 capsid proteins that form “virus-like” particles (VLP) Non-infectious and non-oncogenic Produce higher levels of neutralizing antibody than natural infection HPV Virus-Like Particle All available prophylactic HPV vaccines are made from virus-like particles. The vaccines do not contain any viral DNA and therefore are non-infectious and cannot cause actual disease or cancer. HPV vaccines produce a better immune response than an HPV infection.

HPV Vaccine Comparison This chart demonstrates the HPV types targeted by each HPV vaccine. Bivalent HPV vaccine target two types of HPV, quadrivalent HPV vaccine targets four types of HPV, and 9-valent HPV vaccine targets nine types of HPV. Bivalent, quadrivalent, and 9-valent HPV vaccine all protect against HPV 16 and 18, the HPV types that cause about 66% of cervical cancers and the majority of other HPV-attributable cancers in the United States. Quadrivalent and 9-valent HPV vaccine also protect against HPV 6 and 11, HPV types that cause anogenital warts. In addition, 9-valent HPV vaccine targets five additional cancer-causing types, which account for another 15% of cervical cancers. The additional five types in 9-valent HPV vaccine account for a higher proportion of HPV-associated cancers in women compared with men, and also cause cervical precancers in women. All three vaccines are still licensed in the United States; however, after the end of 2016, however only 9-valent HPV vaccine is currently being marketed in the United States. While clinical trial data show HPV vaccine has high efficacy for prevention of several of the HPV associated precancers in addition to cervical precancers, no clinical trial data are available to demonstrate efficacy for prevention of oropharyngeal or penile cancers. However, because many of these are attributable to HPV16, the HPV vaccine is likely to offer protection against these cancers as well. Genital warts 63% of cancers in body parts where HPV DNA is often found 10% of cancers in body parts where HPV DNA is often found Adapted from Petrosky et al. MMWR. 2015.

HPV Vaccine Recommendation CDC recommends routine vaccination at age 11 or 12 years to prevent HPV cancers  The vaccination series can be started at age 9 years. 2 doses of vaccine are recommended. The second dose of the vaccine should be administered 6 to 12 months after the first dose. HPV vaccine is routinely recommended for adolescents at age 11 or 12 years. For girls and boys starting the vaccination series before the 15th birthday, the recommended schedule is two doses of HPV vaccine. The second dose should be given six to twelve months after the first dose. 21 Meites et al. MMWR. 2016.

HPV Vaccine Recommendations: Catch-Up/Late Vaccination for females through age 26 years and for males through age 21 years who were not previously adequately vaccinated. Males aged 22 through 26 years may be vaccinated. Vaccination is also recommended through age 26 for gay, bisexual, and other men who have sex with men (MSM), transgender people, and people with certain immunocompromising conditions (including HIV infection). ACIP also recommends vaccination for females through age 26 years and for males through age 21 years who were not adequately vaccinated previously. Males aged 22 through 26 years may be vaccinated. Meites et al. MMWR. 2016.

Dosing Schedules Starting the vaccine series before the 15th birthday Starting the vaccine series on or after the 15th birthday* Recommended schedule is 2 doses of HPV vaccine Second dose should be administered 6–12 months after the first dose (0, 6–12 month schedule) Minimum interval between dose 1 and dose 2 in a 2-dose schedule is 5 months Recommended schedule is 3 doses of HPV vaccine Second dose should be administered 1–2 months after the first dose, and the third dose should be administered 6 months after the first dose (0, 1–2, 6 month schedule) Minimum interval between dose one and dose three in a 3-dose schedule is 5 months The new recommendations for HPV vaccine dosing schedules are: For persons initiating vaccination before the 15th birthday, the recommended immunization schedule is 2 doses of HPV vaccine. The second dose should be administered 6–12 months after the first dose (for a 0, 6–12 month schedule). For persons initiating vaccination on or after the 15th birthday, the recommendation for a 3-dose schedule remains. The second dose should be administered 1–2 months after the first dose, and the third dose should be administered 6 months after the first dose (for a 0, 1–2, 6 month schedule). For persons who initiated vaccination with nine-valent, quadrivalent or bivalent HPV vaccine before their 15th birthday, and received two doses of any HPV vaccine at the recommended dosing schedule (zero, six to twelve months), or three doses of any HPV vaccine at the recommended dosing schedule (zero, one to two, and six months), are considered adequately vaccinated. Persons who initiated vaccination with nine-valent, quadrivalent or bivalent HPV vaccine on or after their 15th birthday, and received three doses of any HPV vaccine at the recommended dosing schedule, are considered adequately vaccinated. Nine-valent HPV vaccine may be used to continue or complete a vaccination series started with quadrivalent or bivalent HPV vaccine. For persons who have been adequately vaccinated with quadrivalent or bivalent HPV vaccine, there is no ACIP recommendation regarding additional vaccination with nine-valent HPV vaccine. *And immunocompromised persons 9-26 years Meites et al. MMWR. 2016.

HPV Vaccine Administration Administer HPV vaccines via intramuscular (IM) injection Needle size: 1- to 1½- inch, 22- to 25-gauge Site: Deltoid muscle in the upper arm Follow proper injection practices Use aseptic technique Use a new needle and syringe for each injection Administer at the same medical visit as other adolescent vaccines Administer human papillomavirus vaccines, 2vHPV, 4vHPV and 9vHPV, via intramuscular injection using a 1 to 1 ½ inch, 22 to 25 gauge needle. The preferred site is the deltoid muscle in the upper arm. Always follow aseptic technique when preparing and administering vaccines. A new needle and syringe should be used for each injection. A single dose vial is for one patient only. An adhesive bandage may be applied to the site if bleeding occurs. As discussed, HPV vaccines can be administered during the same clinical visit as other indicated vaccines. CDC Vaccine Administration: https://www.cdc.gov/vaccines/hcp/admin/admin-protocols.html

HPV Vaccine Storage and Handling Store HPV vaccine in a refrigerator between 2°C - 8°C (36°F - 46°F) Store HPV vaccines: In the original packaging with the lids closed In a clearly labeled bin and/or area of the storage unit Do not freeze the vaccine HPV vaccine should be stored in the refrigerator between 2º - 8º C (36º - 46º F). Store vaccine in the original packaging in a clearly labeled bin of are of the storage unit. On the slide is the HPV storage unit label that can be used to identify the vaccine in the storage unit. CDC Vaccine Storage and Handling at www.cdc.gov/vaccines/hcp/admin/storage/index.html Vaccine storage labels at www.cdc.gov/vaccines/hcp/admin/storage/guide/vaccine-storage-labels.pdf

This decision tree is an aid to help vaccine providers vaccinate consistent with current recommendations. www.cdc.gov/hpv/downloads/hpv-2-dose-decision-tree.pdf

HPV Vaccination Is Recommended at Age 11 or 12 Years Girls & Boys can start HPV vaccination at age 9 Preteens should finish the HPV vaccine series before their 13th birthday To recap the HPV vaccine recommendations, both girls and boys can start the HPV vaccine series at age nine. Ideally, preteens should finish the series by their 13th birthday. Girls age 13-26 years old and boys age 13-21 years old who haven’t stared or finished HPV vaccine series should also be vaccinated. Plus girls 13-26 years old who haven’t started or finished HPV vaccine series Plus boys 13-21 years old who haven’t started or finished HPV vaccine series Meites et al. MMWR. 2016.

HPV Vaccine Safety This next section will focus on HPV vaccine safety.

United States Vaccine Safety System Collaborators Description Vaccine Adverse Event Reporting System (VAERS) CDC and FDA Frontline, spontaneous reporting system to detect potential vaccine safety issues Vaccine Safety Datalink (VSD) CDC and 8 integrated health care systems Large-linked database system used for active surveillance and research ~9.4 million members (~3% of US pop) Clinical Immunization Safety Assessment (CISA) Project CDC and 7 academic centers Expert collaboration that conducts individual clinical vaccine safety assessments and clinical research Post-Licensure Rapid Immunization Safety Monitoring Program (PRISM) FDA and 6 partner organizations Large distributed database system used for active surveillance and research ~170 million individuals (~53 of US pop)

Over 10 Years of HPV Vaccine Safety Data HPV vaccines are safe Reactions after vaccination may include: Injection site reactions: pain, redness, and/or swelling in the arm where the shot was given Systemic: fever, headaches HPV vaccines should not be given to anyone who has had a previous allergic reaction to the HPV vaccine or who has an allergy to yeast Brief fainting spells (syncope) and related symptoms (such as jerking movements) can happen soon after any injection, including HPV vaccine Patients should be seated (or lying down) during vaccination and remain in that position for 15 minutes Post licensure HPV vaccine safety data from the United States and other countries over the past 10 years have been robust and reassuring. Based on these data that show the vaccine is safe, what type of side effects do we expect? We know that we can expect HPV vaccination to cause some injection site reactions, possibly fever, and headache. We know that anyone who has any severe allergies, including an allergy to yeast, anyone who has ever had a life-threatening allergic reaction to any component of HPV vaccine or to a previous dose of HPV vaccine, should not be vaccinated. We also know that fainting spells, or syncope, is very common with adolescents when they receive injections. To reduce the risk of syncope patients should be seated while vaccinated and remain in that position or should lay down for 15 minutes. Gee, et al. Hum Vaccine Immunother. 2016.

Evaluating and Monitoring 9-Valent HPV Vaccine Safety in the United States Monitoring of VAERS reports Clinical review of serious reports including deaths and other prespecified adverse events Data mining to identify disproportional reporting Vaccine Safety Datalink Near real-time monitoring of 10 prespecified outcomes Evaluation of spontaneous abortion Sentinel System Active surveillance and surveillance of serious, unexpected events Manufacturer postmarketing commitments Two 10-year studies to assess long-term safety Observational study to further characterize the safety profile in 10,000 persons Pregnancy registry 9-valent HPV vaccine is similar to quadrivalent HPV vaccine in its manufacturing process and content, and the pre-licensure safety data are reassuring. In the United States, the safety of 9-valent HPV vaccine is currently being monitored through review of spontaneous reports, active surveillance, and special epidemiologic studies as listed on this slide.

HPV Vaccination Is Safe HPV vaccine safety studies have been very reassuring: HPV vaccine has a good safety profile. CDC and FDA continue to monitor and evaluate the safety of HPV vaccines, along with all vaccines. Clinicians can reassure parents who may have concerns that HPV vaccination is safe. The safety profile for HPV vaccines is well established. The data from HPV vaccine safety studies have been very reassuring. CDC and FDA continue to monitor and evaluate the safety of HPV vaccines, along with all vaccines. Despite the availability of reassuring data, concerns still persist and have been highlighted in the media, and especially social media, leaving some parents are hesitant to initiate the vaccination series for their children. It is important that clinician reassure parents who may have concerns, that there have been over 10 years of safety data collected for HPV vaccines, and that HPV vaccination is safe. https://www.cdc.gov/vaccinesafety/vaccines/hpv/hpv-safety-faqs.html

Monitoring Impact of HPV Vaccine Programs on HPV-Associated Outcomes This next section will focus on the impact of HPV vaccine. As you can see in the visual here, impact on early outcomes such as HPV prevalence and genital warts can be demonstrated in just a few years after vaccine introduction. Because of the delay between infection and pre-cancer and then cancer, it will take longer to see impact on disease. HPV Vaccine Impact

HPV Vaccine Impact Monitoring Postlicensure evaluations are important to evaluate real-world effectiveness of vaccines Population impact against early and mid outcomes has been reported in many countries, including: HPV prevalence Australia, Norway, Denmark, Sweden, Switzerland, UK, U.S. Genital warts Australia, Belgium, New Zealand, Denmark, Sweden, Germany, Quebec, U.S. Cervical lesions Australia, British Columbia, Denmark, Scotland, Sweden, U.S. HPV vaccination impact can be monitored through post-licensure evaluations of the various outcomes of HPV infection, including HPV prevalence, genital warts, and precancerous cervical lesions. Reduction in each of these outcomes have been reported in a number of countries.

HPV Vaccine Impact in the U.S. Declines observed in: Vaccine type prevalence Genital warts Cervical precancers In the United States, vaccine impact has now been observed on vaccine type prevalence, genital warts and cervical precancers; I will review just some of these data on vaccine type prevalence in the following slides.

Vaccine Type Prevalence Among Females, NHANES Early vaccine era compared to pre-vaccine era In the United States, dramatic impact of the vaccination program has been observed among females in NHANES. This graph demonstrates vaccine type prevalence by era the prevaccine in grey and the early vaccine era 2007-2010 in blue. Four age groups are examined, as shown on x axis; prevalence on the y-axis. There was a 56% decrease in vaccine type prevalence among 14 to 19 year old females in the early vaccine era, compared to the pre-vaccine era, in gray. No changes were detected among the older age groups. Markowitz et al. JID 2013;208:385-393

Vaccine Type Prevalence Among Females, NHANES Later vaccine era compared to pre-vaccine era Further decreases in vaccine-type prevalence were seen in the later vaccine era. This group shows the prevaccine era in grey, the early vaccine era in blue and the later era (2011-2014), in red. Among 14 to 19 year old females, there was a 71% decrease. Additionally, there was a 61% decrease among 20 to 24 year old females, but no significant changes were detected among the other age groups. Oliver et al. JID 2017

Impact of HPV Vaccination in Australia Proportion of Australian-born females and males diagnosed as having genital warts at first visit, by age group, 2004-11 Males This slide shows data on genital warts from Australia. The HPV vaccination program in Australia began in 2007 shown by the vertical dashed line. The program initially targeted only female adolescents with catchup through age 26 years; High coverage was reached quickly through school based vaccination. In the left panel, you can see from the teal blue solid line, diagnoses of genital warts decreased dramatically in females under age 21 years soon after start of the vaccine program. A decline was also seen in women 21-30 years. In the right panel, you can see a similar decrease in diagnoses of genital warts in males in these two age groups. Even though males were not being vaccinated. This is probably indicative of a reduction in transmission and herd protection. Females Ali et al. BMJ. 2013

Systematic Review and Meta-Analysis: Population-Level Impact of HPV Vaccination Review of 20 studies in 9 high-income countries In countries with >50% coverage, among 13-19 year-olds HPV 16/18 prevalence decreased at least 68% Anogenital warts decreased by ~61% Evidence of herd effects Some evidence of cross protection against other types These are just two of the studies that have now been published to examine the real-world impact of HPV vaccination. In 2015 a systematic review and meta-analysis of these studies was published which summarized the population-level impact of HPV vaccination. In countries where the HPV vaccine coverage rates were 50% and above among teens, prevalence of infection with HPV 16 and HPV 18 decreased by more than two-thirds and prevalence of anogenital warts decreased by nearly two-thirds. The review found that there is evidence of both herd effects as well as protection with other HPV types not included in the vaccines. Drolet et al. Lancet Infect Dis. 2015

HPV Vaccine Duration of Protection Studies suggest that vaccine protection is long-lasting No evidence of waning protection Available evidence indicates protection for at least 10 years Multiple studies are in progress to monitor HPV vaccine has been available in the United States for 10 years. Long-term studies of patients from clinical trials provide data showing there is no evidence that protection against the vaccine types will decrease over time. ACIP. Summary Report. June 22-23, 2016.

HPV Vaccination Is Safe, Effective, and Provides Lasting Protection HPV Vaccine Is SAFE Benefits far outweigh any potential risks Safety studies findings for HPV vaccination are reassuring and similar to MenACWY and Tdap vaccine safety reviews HPV Vaccine WORKS Population impact against early and mid outcomes has been reported in multiple countries HPV Vaccine Protection LASTS Studies suggest that vaccine protection is long-lasting No evidence of waning protection HPV vaccine is safe, effective and provides lasting protection against the types of HPV that most commonly cause cancer.

Framing the conversation Talking About HPV Vaccine This next section focuses on strategies to improve HPV vaccine recommendations and conversations with patients and their parents Framing the conversation

Adolescent Vaccination Coverage United States, 2006-2016 New APD definition* As you can see, the rates of first and third dose of HPV vaccine are not nearly as high as the coverage rates for the other vaccines routinely recommended for 11 and 12 year olds. However, the very important piece of information that this slide provides is that the strong coverage rates for Tdap vaccine demonstrate that not only are most preteens and teens getting to the doctor, but they are also getting at least one of the recommended adolescent vaccines. *APD = Adequate provider data; †≥2 doses MenACWY among adolescents aged 17 years Walker et al. MMWR 2017.

Impact of Eliminating Missed Opportunities by Age 13 Years in Girls Born in 2000 A missed clinical opportunity for HPV vaccination is defined as a healthcare encounter when some, but not all ACIP-recommended vaccines are given. Had HPV vaccine been administered during health care visits when another vaccine was administered, vaccination coverage for at least one 1 dose could have reached 91.3% by age 13 years for adolescent girls born in 2000. High HPV vaccination coverage with existing infrastructure and health-care utilization is possible in the United States. Taking advantage of every health-care encounter, including acute-care visits, to assess every adolescent’s vaccination status can help minimize missed opportunities. Potential strategies include using vaccination prompts available through electronic health records or checking local and state immunization information systems to assess vaccination needs at every encounter. Series completion also can be promoted through scheduling appointments for second and third doses before patients leave providers’ offices after receipt of their first HPV vaccine doses and with automated reminder-recall systems. Stokley et al. MMWR. 2014.

Parents of unvaccinated girls – top reasons for not starting HPV vaccine series Studies consistently show that a strong recommendation from you is the single best predictor of vaccination for any vaccine, including HPV vaccine. In the 2013 NIS-Teen nearly 15% of parents who said that they would not be getting their child vaccinated against HPV in the next 12 months, identified not receiving a recommendation as one of the top reasons not to vaccinate. Stokley et al. MMWR. 2014.

Value Parents Place on the Vaccines These data are from research conducted by Dr. Mary Healy and colleagues in Texas, with parents regarding immunization for their children. When parents were asked how much value they placed on each of the vaccines, you can see that they ranked these vaccines similarly. Adapted from Healy et al. Vaccine. 2014.

Clinician Estimations Providers were asked to estimate how much value parents placed on the same vaccines. As you can see, they guessed correctly for vaccines protecting against meningitis, hepatitis, pertussis. Adapted from Healy et al. Vaccine. 2014.

Clinicians Underestimate the Value Parents Place on HPV Vaccine However, the estimates that clinicians gave for how much value parents place on flu and HPV vaccination are much lower. These clinicians underestimated the value parents place on HPV vaccine. This is evidence of a big disconnect between parents and clinicians. Adapted from Healy et al. Vaccine. 2014.

“The perceived and real concerns of parents influence how clinicians recommend HPV vaccine.”

Give an Effective Recommendation to Receive HPV Vaccine at Age 11 or 12 An effective recommendation from you is the main reason parents decide to vaccinate Many moms in focus groups stated that they trust their child’s clinician and would get the vaccine for their child as long as they received a recommendation from the clinician A clinician’s recommendation is the number one reason parents decide to protect their children with vaccination. Regardless of the perceived or real concerns of a parent, an effective recommendation for all adolescent vaccines needs to be given. There is a strong evidence base to support the importance of an effective recommendation. Smith et al. Vaccine. 2016. Unpublished CDC data, 2013.

EFFECTIVE What is an recommendation for HPV vaccination? So that begs the question. What IS an effective recommendation for HPV vaccination?

Same Way Same Day The best and most effective recommendation for HPV vaccination is when HPV vaccine is recommended in the same way and on the same day as the other vaccines recommended for girls and boys at ages 11 and 12 years.

Make an Effective Recommendation Same way: Effective recommendations group all of the adolescent vaccines Recommend HPV vaccination the same way you recommend Tdap and meningococcal vaccines Same day: Recommend HPV vaccine TODAY Recommend HPV vaccination the same day you recommend Tdap and meningococcal vaccines Successful recommendations group all of the adolescent vaccines Recommend the HPV vaccine series the same way you recommend the other adolescent vaccines Brewer at al. Pediatrics. 2017. Unpublished CDC data, 2013.

Your preteen needs three vaccines today to protect against meningitis, HPV cancers, and pertussis. I want to point out a few things on this slide. The word “today” is especially important because it conveys to the parent that you are recommending that all of these vaccines be given today, not another day. The order of the vaccine-preventable diseases is also important. We want to sandwich HPV cancers between meningococcal and Tdap vaccines. This makes it more normalized and gives it the same importance as the other two adolescent vaccines. Where as if it’s the last one mentioned it can seem more of an after thought or that you need to have more of a discussion about it later on. Brewer at al. Pediatrics. 2017.

Preteen Vaccines HPV Tdap MenACWY We call this the “bundled recommendation” because it bundles all of the vaccines recommended for preteens into one effective and presumptive statement.

Now that Sophia is 11, she is due for three vaccines Now that Sophia is 11, she is due for three vaccines. These will help protect her from the infections that can cause meningitis, HPV cancers, and pertussis. We’ll give those shots today. So you could say something like “now that Sophia is 11, she is due for three vaccines. These will help protect her from meningitis, HPV cancers, and pertussis. We’ll give those shots today.”

Now that Sophia is 11, she is due today for three important vaccines Now that Sophia is 11, she is due today for three important vaccines. The first is to help prevent an infection that can cause meningitis, which is very rare, but potentially deadly. The second is to prevent a very common infection, HPV, that can cause several kinds of cancer. The third is the tetanus booster which also protects against pertussis, so she doesn’t get whooping cough. We’ll give those shots at the end of the visit. Do you have any questions for me? Some of you may feel more comfortable with saying a bit more about each of the vaccines being recommended. Here’s another way to make the bundled recommendation. You can say “Now that your child is 11/12, she is due today for three important vaccines. The first is to help prevent an infection that can cause meningitis, which is very rare, but potentially deadly. The second is to prevent a very common infection—HPV—that can cause several kinds of cancer. The third is the “tetanus booster” which also protects against pertussis, so your child doesn’t get whooping cough, but also to protect babies too young to be vaccinated. We’ll give those shots at the end of the visit. Do you have any questions for me?”

Some Parents Need Reassurance Many parents simply accept this bundled recommendation Some parents may be interested in vaccinating, yet still have questions. Interpret a question as they need additional reassurance from YOU, the clinician they trust with their child’s health care Ask parents about their main concern (be sure you are addressing their real concern) Many parents will accept the bundled recommendation without any questions. Other parents may be interested in vaccinating, yet still have questions for you. A question from a parents about HPV vaccine does not mean they are refusing or delaying. Many parents with questions about HPV vaccine are looking for additional reassurance from you. Taking the time to listen to parents’ questions helps you save time and give an effective response. Be sure to verify that you are addressing the right concern. Unpublished CDC data, 2013.

Why does my child need HPV vaccine? Some parents may ask, “Why does my child need HPV vaccine?” This question may also sound like “My daughter doesn’t really need THAT vaccine, does she?” Regardless of how parents ask that question we want them to know that this vaccine is very important for cancer prevention.

HPV vaccination is important because it prevents cancer HPV vaccination is important because it prevents cancer. That’s why I’m recommending that your child start the HPV vaccine series today. You can respond to them by saying, “HPV vaccination is important because it prevents cancer. That’s why I’m recommending that your child start the HPV vaccine series today.”

What cancers are caused by HPV infection? CDC research with parents has shown that many parents aren’t aware of all of the cancers that can be caused by persistent HPV infection, so some parents may ask you about the cancers that are caused by HPV infection.

Persistent HPV infection can cause cancer of the cervix, vagina, and vulva in females, cancer of the penis in males, and cancers of the anus and the throat in both. We can help prevent infection with the HPV types that cause these cancers by starting the HPV vaccine series today. You can tell parents that “persistent HPV infection can cause cancer of the cervix, vagina, and vulva in females, cancer of the penis in males, and cancers of the anus and the throat in both. We can help prevent infection with the HPV types that cause these cancers by starting the HPV vaccine series today.”

Is my child really at risk for HPV? It’s hard for parents to see their 11 or 12 year old as being at risk for HPV infection and they make ask about that risk.

HPV is a very common virus that infects both females and males HPV is a very common virus that infects both females and males. We can help protect your child from the cancers and diseases caused by the virus by starting HPV vaccination today. Focus on how common HPV is and how they can protect their child from cancer by saying something like “HPV is a very common virus that infects both females and males. We can help protect your child from the cancers and diseases caused by the virus by starting HPV vaccination today.”

Why at 11 or 12 years old? Asking why now, or why at 11 or 12, is another way that parents may say that they think their child is too young for “that” kind of behavior, in other words, sexual activity. Help parent understand the importance of vaccination before exposure and that we don’t wait for exposure to occur, or guess when it will occur, before vaccinating.

When should the bike helmet go on? Before they get on their bike When they are riding their bike in the street When they see the car heading directly at them After the car hits them Most people are familiar with, and endorse the use of bicycle helmets. You could also use seatbelts as an example. Ask parents, “When do you want your children to put on their bike helmets? Make the point that we can’t guess when the bike accident risk may occur so we always have our children put on their helmets before getting on their bikes. Temte JL. Pediatrics 2014.

When do we put our seat belts on? Before turning on car When leaving driveway After a near accident You could also use seatbelts as an example. Ask parents, “When do we put our seat belts on?” Temte JL. Pediatrics 2014.

As with all vaccine-preventable diseases, we want to protect your child early. If we start now, it’s one less thing for you to worry about. Also, your child will only need 2 shots of HPV vaccine at this age. If you wait until 15, your child will need three shots. We’ll give the first shot today and then you’ll bring your child back in 6 to 12 months for the second shot. Or you can just say, “As with all vaccine-preventable diseases, we want to protect your child early. If we start now, it’s one less thing for you to worry about. Also, your child will only need two shots of HPV vaccine at this age. If you wait until 15, your child will need three shots. We’ll give the first shot today and then you’ll need to bring your child back in 6 to 12 months from now for the second shot.”

I’m just worried that my child will perceive this as a green light to have S-E-X. Parents continue to bring concerns about sexual disinhibition following vaccination.

Numerous research studies have shown that getting the HPV vaccine does NOT make kids more likely to be sexually active or start having sex at a younger age. Starting the HPV vaccine series today will give your child the best possible protection for the future. You can reassure these parents that “Numerous research studies have shown that getting the HPV vaccine does not make kids more likely to be sexually active or start having sex at a younger age. Starting the HPV vaccine series today will give your child the best protection possible for the future.”

How long can we wait and still give just two doses? The new two-dose recommendation may cause some parents to think that they can wait another year… or three.

The two-dose schedule is recommended if the series is started before the 15th birthday. However, I don’t recommend waiting to give this cancer-preventing vaccine. Older teens have busier schedules and it becomes more difficult to schedule an appointment. It’s best to start the series today so your child is protected as soon as possible. You can tell these parents, “The two-dose schedule is recommended if the series is started before the 15th birthday. However, I don’t recommend waiting to give this cancer-preventing vaccine. Older teens have busier schedules and it becomes more difficult to schedule an appointment. It’s best to start the series today so your child is protected as soon as possible.”

Do you really know if it’s safe? I’m concerned about the safety of the vaccine—I read things online that say HPV vaccine isn’t safe. Do you really know if it’s safe? Naturally, some parents will have questions about HPV vaccine safety.

It sounds like you want what’s best for your child and have concerns about the safety of HPV vaccine. Is that right? We both want what’s best for your child. Can you tell more about your concerns? I have researched HPV vaccine including safety. Can I share with you what I have learned? You could start with something like, “It sounds like you want what’s best for your child and have concerns about the safety of HPV vaccine. Is that right? We both want what’s best for your child. Can you tell more about your concerns? I have researched HPV vaccine including safety. Can I share with you what I have learned?” and then share that specific information with them.

I know there are stories in both the media and online about vaccines I know there are stories in both the media and online about vaccines. However, I want you to know that HPV vaccine has been carefully studied for many years by medical and scientific experts. Based on all these studies, I believe HPV vaccine is very safe. It is important to acknowledge a parent’s concerns. Try saying something like “I know there are stories in both the media and online about vaccines. However, I want you to know that HPV vaccine has been carefully studied for many years by medical and scientific experts. Based on all these studies, I believe HPV vaccine is very safe. .”

Vaccines, like any medication, can cause side effects Vaccines, like any medication, can cause side effects. With HPV vaccination, this could include pain, swelling, and/or redness where the shot is given, or possibly a headache. No serious side effects have been associated with HPV vaccine. If safety concerns are specific to adverse events, explain to parents that “Vaccines, like any medication, can cause side effects. With HPV vaccination, this could include pain, swelling, and/or redness where the shot is given, or possibly a headache. No serious side effects have been associated with HPV vaccine.”

Can HPV vaccine cause future fertility problems? Sometimes vaccine safety questions can be very specific.

There is no evidence available to suggest that HPV vaccine will affect future fertility. However, women who develop cervical cancer could require treatment that would limit their ability to have children. Starting the HPV vaccine series today could prevent that from happening and protect your daughter’s ability to bear children. If you get a question about fertility concerns you can say “There is no evidence available to suggest that getting HPV vaccine will have an effect on future fertility. However, women who develop cervical cancer could require treatment that would limit their ability to have children. Starting the HPV vaccine series today could prevent that from happening and protect your daughter’s ability to bear children.”

How do you know if the vaccine works? Parents may voice concerns about vaccine effectiveness.

Ongoing studies continue to show that HPV vaccination works very well Ongoing studies continue to show that HPV vaccination works very well. HPV infections, genital warts, and cervical precancers in young people have all decreased in the years since the vaccine has been available. Starting the vaccine series today will help ensure your child gets the best protection possible. You can let parents know that “Ongoing studies continue to show that HPV vaccination works very well. HPV infections, genital warts, and cervical precancers in young people have all decreased in the years since the vaccine has been available. Starting the vaccine series today will help ensure your child gets the best protection possible.”

Why do boys need to be vaccinated? As I mentioned previously, many parents are not aware of HPV disease in men and may ask why their male child needs to be vaccination.

HPV infection can cause cancers of the penis, anus, and throat in men HPV infection can cause cancers of the penis, anus, and throat in men. HPV infection can also cause genital warts. Getting HPV vaccine today for your son can help prevent the infection that can lead to these diseases. It is important for parents to know that HPV infection causes cancer in men as well. You can say something like “HPV infection can cause cancers of the penis, anus, and throat in men and it can also cause genital warts. Getting HPV vaccine today for your son can help prevent the infection that can lead to these diseases.”

We only want the vaccines needed for school. Occasionally parents will ask you, “why should I get my child the HPV vaccine if it’s not requit

School-entry requirements don’t always reflect the current recommendations to keep your child healthy. HPV vaccine, along with other adolescent vaccines, will provide your child with the best protection. It is important to explain the difference between a recommendation that you are making for the health of your child, versus a legislative decision that is designed to keep kids who may have missed a vaccination from slipping through the cracks. Letting parents know that you, along with CDC and the major medical societies, recommend all of the vaccines equally for their child’s health can help them understand that HPV vaccination is a normal part of adolescent health. You can share with them that “school-entry requirements don’t always reflect the current recommendations for their child’s health.”

Would you give HPV vaccine to your kids? Occasionally parents will ask you or another person in your medical office if you or they would give HPV vaccine to you/their kids.

Yes, I have given HPV vaccine to my child Yes, I have given HPV vaccine to my child. I believe strongly in the importance of this cancer-preventing vaccine. Also, the American Academy of Pediatrics, the American Academy of Family Physicians, NIH cancer centers, and CDC agree that HPV vaccination is very important for your child. If you have vaccinated you child, you can share that with parents by saying something to the effect of “Yes, I have given HPV vaccine to my child. I believe strongly in the importance of this cancer-preventing vaccine. Also, the American Academy of Pediatrics, the American Academy of Family Physicians, NIH cancer centers, and CDC agree that HPV vaccination is very important for your child.?

I heard there is a new HPV vaccine that works better I heard there is a new HPV vaccine that works better. Should I be getting that for my child who already was vaccinated? Parents with children who have already started or finished the HPV vaccine series with bivalent or quadrivalent HPV vaccine may ask about 9-valent HPV vaccine.

Currently there is no recommendation for additional vaccination for someone who has already completed an HPV vaccine series. All HPV vaccines protect against the infections that cause most of the cancers. For a parent who ask about having their child receive additional HPV vaccinations, let them know that “Currently there is no recommendation for additional vaccination for someone who has already completed an HPV vaccine series. All HPV vaccines protect against the infections that cause most of the cancers.”

When do we need to come back? A recent study highlighted the need for parents to be told when they need to bring their child in for the remaining doses. Most parents do not know how many shots are in the series or what the intervals are.

Since your child is younger than 15, she will need a second shot in 6 months to a year. When you check out, please make sure to make an appointment for the second shot and put that appointment on your calendar before you leave today! If their child is younger than 15, tell parents, “Since your child is younger than 15, she will need a second shot in 6 months to a year. When you check out, please make sure to make an appointment for the second shot and put that appointment on your calendar before you leave today!”

Since your child is already 15, she will need a second shot in 1-2 months. The third shot is due 6 months from today. When you check out, please make sure to make an appointment for about 1-2 months from now and 6 months from now, and put those appointments on your calendar before you leave today! If their child is 15 or older then tell parents, “Your child will need a second dose in 1-2 months. The third dose will be due in 6 months from today. When you check out, please make sure to make an appointment for about 6 weeks from now and 6 months from now, and put those appointments on your calendar before you leave today!”

My child is less than 15 years old, so why does she need a third shot? Some parents may have additional questions about the new dosing schedule.

The recommended schedule is 2 shots given 6 to 12 months apart The recommended schedule is 2 shots given 6 to 12 months apart. The minimum amount of time between those shots is five months. Because your child received two shots less than five months apart, we’ll need to give your child a third shot. Try saying, “The recommended schedule is 2 shots given 6 to 12 months apart. The minimum amount of time between those shots is five months. Because your child received two shots less than five months apart, we’ll need to give your child a third shot.”

Will my child be protected with just two shots? This question is more common for parents with older children who have completed the 3-dose series.

Yes! Studies have shown that just two shots given at least six months apart, when the first dose is given between 9 and 14 years, worked as well or better than three shots given to older adolescents and young adults. Reassure those parents that “Yes! Studies have shown that just two shots given at least six months apart when kids are between 9 and 14 years worked as well or better than three shots given to older adolescents and young adults.”

If a Parent Doesn’t Say Yes Today… Ask Clarify and restate their concerns to make sure you understand Acknowledge Emphasize it is the parents’ decision Acknowledge risks and conflicting info sources Applaud them for wanting what is best for their child Be clear that you are concerned for the health of their child–not just public health safety Advise Allow time to discuss the pros and cons of the vaccine Be willing to discuss parents’ ideas Offer written resources for parents Tailor your advice using this presentation A few parents will be hesitant. Here’s a detailed approach to the hesitant parent, based on childhood vaccination work by Vax Northwest. The steps include: Ask, Acknowledge, & Advise. In short… -Ask about their concern -Acknowledge that you know they want to keep their child safe and healthy in every way….and so do you. -And then advise them on why you recommend getting HPV vaccination now. Adapted from Henrickson, Vax Northwest 2014.

If a Parent Declines Today Declination is not final. The conversation can be revisited End the conversation with at least one action you both agree on Because waiting to vaccinate is the risky choice, many pediatricians ask the parent to sign a declination form Some parents will not accept your recommendation for their child this year. But that doesn’t mean they won’t ever have their child protected with HPV vaccination. Make sure you leave the door open to revisit the conversation at the following annual visit.

Ensure ALL Your Patients are Protected Align office/clinic policy with mission Immunize at every opportunity Implement and utilize standing orders Prompt the clinician to assess and administer the vaccine EMRs, IIS, etc. Reminder and recall www.cdc.gov/hpv/downloads/Top10-improving-practice.pdf

CDC has a variety of resources available to assist clinicians in communicating about HPV vaccine and improving practice to increase immunization rates. Visit CDC.gov slash HPV and click on the section for clinicians. www.cdc.gov/hpv

Keeping All Staff On the Same Page Align communication with mission Give staff a cancer-prevention mission All staff need to be saying the same thing Share talking points Use the Tip Sheet Educate staff about HPV vaccine recommendations including schedule, administration, storage and handling Make sure that all clinic staff, including those answering the phone and making appointments, are communicating the same way about HPV vaccine. Put the focus on cancer prevention and provide talking points for the staff. One way to be sure that staff have the information that they need is to share with them the tip sheet “Addressing Parents’ Top Questions about HPV Vaccine.” www.cdc.gov/hpv/hcp/for-hcp-tipsheet-hpv.pdf

Keeping All Staff On the Same Page Multiple education products available free through the CDC website: Immunization courses (webcasts and online self-study) Netconferences You Call the Shots self-study modules Continuing education available Make sure that all clinic staff, including those answering the phone and making appointments, are communicating the same way about HPV vaccine. Put the focus on cancer prevention and provide talking points for the staff. One way to be sure that staff have the information that they need is to share with them the tip sheet “Addressing Parents’ Top Questions about HPV Vaccine.” CDC immunization education and training: www.cdc.gov/vaccines/ed/index.html

Ensure ALL Your Patients are Protected Know your coverage rates– CDC’s AFIX can help Clinic-level rates are great, but rates for individual clinicians are even better Other than coverage assessment and feedback (including AFIX), rates can come from: Data from EHR Immunization Information Systems (IIS) inputs The first is to know what your rates are. We only improve what we measure. There are a variety of ways to do this. If you are a VFC provider, ask for and attend the next AFIX site visit. If that is not available or won’t be happening soon, have data pulled from your EHR or IIS inputs for all of your 13 year old patients.

HPV VACCINE IS CANCER PREVENTION And YOU are the key! #WeCanStopHPV

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